Does Motivational Interviewing Prevent Early Childhood Caries? A Systematic Review and Meta-Analysis

Statement of the Problem:
 Early childhood caries (ECC) is a serious public health concern in the world. Motivational interviewing (MI) has been used to prevent ECC as a scientifically tested method for advising patients. 
Purpose:
 The present study aimed to evaluate the effectiveness of MI on prevention of ECC and identify factors shaping outcomes. 
Materials and Method:
 A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted using MI as the intervention and the decay-missing-filled index (dmfs) report as result. Databases including Web of Science, PubMed, Scopus, PsycINFO and Cochrane Library were systematically searched to recognize relevant RCTs evaluating the effects of MI on prevention of ECC from the beginning of 1989 to April 2020. Mean difference and 95% confidence intervals were summarized using a fixed-effect model. Visual inspection of Egger's test was used for potential publication bias in this study. 
Results:
 Six studies comprising 2776 contributors showed that MI had a significant effect on preventing ECC. There was no significant publication bias in the meta-analysis. A sensitivity analysis demonstrated that deleting any of the studies could not affect the significance of pooled results. This meta-analysis showed that MI might prevent ECC. 
Conclusion:
 MI will be effective at any age, whether it is a baby or a child, and more than the number of interview sessions, the quality of the sessions should be considered. Moreover, follow-up for at least 3 years will be very effective.


Introduction
Early childhood caries (ECC) is now a serious public health concern in developing and industrialized countries [1]. ECC is considered as "the presence of one or more decayed (non-cavitated or cavitated lesions), missing teeth (due to caries), or filled tooth surfaces in any primary tooth in a child 72 months of age or younger".
In children younger than 3 years, any evidence of smooth-surface caries is defined as severe early childhood caries (S-ECC) [2]. ECC can begin early in life and often goes untreated; it indicates the beginning of an incre-asingly association of oral health and quality of life [3].
The association of ECC with the socioeconomic status (SES) has been well studied and documented. Studies showed that ECC is commonly found in children below the poverty line or with poor economic status and ethnic and racial minorities [4][5][6] and children with single mothers [7], whose parents (especially mothers) have low educational level [4,8]. Furthermore, parental or caregiver behaviors play a key role in a child's life, including regular dental care [9]. Therefore, parents or caregiver's beliefs, attitudes, performance, self-efficacy and social status will affect the oral health-promoting behaviors, thereby influencing ECC development [9][10].
For ECC management strategies, there are parent interviews to determine risk-related variables, such as socioeconomic factors [11]. In this regard, dental public health has employed a brief patient-centered counseling technique called motivational interviewing (MI) that focuses on practitioner's skills to motivate parents to adopt management strategies for ECC rather than directing those choices [12][13][14].
MI was first used as a treatment tool for addictive behaviors and seemed to have a continued impact over time. More recently, it has been used as a successful strategy for chronic diseases or conditions affected by unhealthy lifestyle [1,15]. Harrison et al. [16] reported that MI interventions had an impact on the severity of caries in children and decision-making between a parent/caregiver and an oral health provider for ECC management in Quebec, Canada. In another literature, Henshaw et al. [17] admitted MI counseling did not improve oral health behaviors caries increment.
There are conflicts in results of different studies based on clinical evidence of MI effectiveness on preventing ECC [18][19][20].

Objective
We conducted a systematic review and meta-analysis of RCTs to obtain a pooled assessment of the impact of MI on preventing ECC. The present study was based on Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) [21].

Materials and Method
Two independent reviewers (R.J. and F.M.) undertook the systematic search using online databases consisted of Web of Science, PubMed, Scopus, PsycINFO, and Cochrane Library for all relevant published works investigating MI to prevent ECC without any restriction from inception up to 30 April 2020.
The following search scheme was planned for search in titles and abstracts: ("motivational interviewing" OR "motivational counseling" OR "motivational interview" OR "motivation interviewing" OR "directive counseling" OR "psychological intervention" OR "transtheoretical model" OR "stages of change" OR "readiness to/for change") AND ("dental caries" OR "dental decay" OR "teeth caries" OR "teeth decay" OR "tooth caries" OR "dmf index" OR "ECC" OR "early childhood caries") AND ("clinical" OR "randomi*" OR "Trial" "control" OR "blind" OR "intervention" OR "randomized"). In addition, to improve the search strategy sensitivity, the wild-card term "*" was used. Included records' reference lists, Google Scholar, and review literature were hand-searched to find eligible documents and prevent missing potential literature. For moderate duplicates detecting and the publication screening, was used End-Note X7 software.

Data selection
The remained studies were reviewed by two authors (R.J. and F.M.), independently, to see if they were appropriate for inclusion. After removing duplicate records, the screening method was done in two phases.
Initially, the titles and abstracts of articles were reviewed. Then, the remaining articles were reviewed in the second phase to be eligible using the full text. The desired data were extracted using a predefined checklist containing the last name of first authors, publication date, trials' location, age, sample size, duration of intervention, duration of follow-up and quality of the included literature independently by R.J. and F.M. and any doubts were resolved by S.A.

Quality assessment
In order to evaluate the quality of eligible trial articles, Jadad scale was used with a maximum of five points (blindness and randomization scored two points and descriptions of dropout scored one point). Trials with more than 3 points were considered as high quality and the others as low quality studies [23].

Statistical analysis
All data were analyzed using Stata v13. A fixed-effect model was used to 95% CI and pool weighted mean difference (WMD). For a chi-square, statistical heterogeneity was estimated using I 2 (high ≥ 50%, low < 50%) [24] was assessed using I 2 (high ≥ 50%, low < 50%) for chi-square [25]. Egger test was used for results with more than two effect sizes for potential publication bias [26]. Eliminating one study at a time as sensitivity analysis was executed, to evaluate the impact of each study on the pooled results. A p value less than 0.05 (typically ≤ 0.05) was statistically significant.

Data selection
The selection process of the study is shown in Figure 1.
In sum, a systematic search of online databases identi-fied 256 articles (PubMed: 61, Scopus: 60, Web of Science: 66, PsycINFO: 13 and Cochrane library: 56). One hundred and fifty-five articles were deleted due to duplication. Ninety-two articles were deleted by screening titles/abstracts because did not comply the inclusion criteria. Therefore, 11 studies were evaluated for competency and displayed with full text. Eventually in the present meta-analysis, six full-text articles were contained [14,[18][19][20][27][28].

Trial specifications
Specifications of the selected studies are described in Table 1 (Table 1).

Meta-analysis
As shown in Figure 2 Table 2 showed that high heterogeneity disappeared in the analysis of following subgroup: age (up to 1 year, more than 1 year), number of visits (up to 2), duration of visits (more than 200 min) and duration of study (12 months, 36 months).

Publication bias and sensitivity analysis
The omission of the studies could not affect the significance of the pooled results based on the sensitivity analysis ( Figure 3). No confirmation of published bias for E-CC was found significantly (Egger's test p= 0.66).

Discussion
Based on this systematic review and meta-analysis study on RCTs, MI prevents ECC. The studies that had the inclusion criteria for our study, followed children over a period of one to three years and by measuring the dmfs index, they showed that MI has a significant effect on preventing ECC.
In selected studies, different methods have been used in the control group. Jiang et al. [18] used three pamphlets entitled "Cleaning Teeth -I can do it", "Eat Appropriately", and "Early Childhood Caries" to educate mothers. In addition to the pamphlet, Harrison et al. [14] used an 11-minute instructional video called Preve-  Batliner et al. [28] discussed eight topics in MI sessions: taking your child to the dentist, only water in sippy cup in bed, transition to cup by 1 y, offer non-sugary foods, germs cause cavities, protect with fluoride, clean mouth / brush 2 times daily, and take care of your own teeth.
Henshaw et al. [20]    The authors also used the motivational interviewing treatment integrity (MITI) scale [29] and written tests to assess the adequacy of the MI team [18,20,28]

Conclusion
This meta-analysis demonstrated that MI might prevent ECC. Providing sufficient information and care tools alone cannot be effective and efforts should be made to create a better understanding of oral health in families.
MI will be effective at any age, whether it is a baby or a child, and the quality of the sessions should be considered more than the number of interview sessions. Families should not be abandoned and the follow-ups should be done so that MIs can be most effective in preventing ECC. Using this method will help create a society with fewer oral problems.